“I constantly think of cheating on my wife,” says 40-year-old Omar Khan*, the owner of a successful advertising firm in Karachi, as he waits in the lounge of a prominent psychological institute in Defence.

The suited gentleman is quite forthcoming regarding his reasons for visiting a therapist, whom we visits every week for an hour-long session despite a hectic schedule.

“I was young when I got married, had children early, and my wife suddenly became too busy for me,” he explains. “Over time, my frustration grew so much that I didn’t even realise when I started thinking of other, younger women. When I did realise this, I knew it was wrong but I couldn’t stop and the back and forth topped with the guilt of it all was just killing me.”

Several months into therapy, Khan began slowly untying the knots that had twisted his life into a tangle.

“It began with anger management but the person I was really angry at was myself,” he shares.

Omar initially started therapy for anger-management issues; business was shaky for a few years, causing him to lose patience with people at work and at home. One day, he struck his five-year-old son.

“That was the last straw. I knew I needed help.”

But what he didn’t want was to be prescribed medication to control his moods and behaviour. This is when he discovered cognitive behavioural therapy, also well-known by its abbreviation CBT.

CBT is among the a range of options available for people seeking therapeutic help without, or alongside their medicines.

The therapy aims at altering how you think (cognitive) resulting in fixing what you do (behaviour). It is mostly applied when dealing with people suffering from depression, anxiety, obsessive-compulsive disorders, phobias and post-traumatic stress disorder (PTSD).

Chart by Manzar Elahi

Within the last decade CBT has gained significant popularity in Pakistan, specifically since the Pakistan Association for Cognitive Therapists (PACT) was formed in 2009.

“Abroad there are many institutes that are dedicated to CBT, which can also be taken as a sub-discipline, but in Pakistan this has become a popular approach over the last few years or so,” says Kiran Bashir Ahmad, a senior lecturer at Institute of Professional Psychology at Bahria University and a PhD scholar.

The reason for CBT’s delay into Pakistani mainstream psychological preferences, according to Ahmed, is because most of the previous heads of institutes were mainly trained in psychoanalytic or psychodynamic schools of thought (originating from Sigmund Freud, Carl Jung or Alfred Adler) and were not necessarily in favour of subscribing to what was mostly looked upon as ‘talk therapy’.

All that has changed now and the underlying connection between our thoughts and feelings playing a significant role in our behaviour has gained traction among practising psychologists and psychiatrists alike.

While both CBT and psychodynamic therapy (PDT) are geared towards reducing distress, a critical difference between the two is that PDT attempts to create a deeper understanding of one's behaviour and motivations whereas CBT is more focused on replacing dysfunctional thoughts and patterns with more realistic and helpful ones without delving too much into root causes.

CBT in Pakistan

“There are many non-invasive therapies available, such as CBT. We do encourage [students and other practising psychologists] to explore them before they opt for medication,” says Head of Department of Psychology at DHA College for Women Mohadesa Mohammed.

In the same vein, vice president for PACT and a clinical psychologist Mirrat Gul says, “International guidelines [American Psychiatric Association, WHO, World Psychiatric Association] recommend, apart from medicine, CBT as the best therapy for everybody – illiterate or educated.”

PACT’s efforts revolve on adopting and adapting therapies, namely CBT, in accordance to local norms and needs.

Nausheen Shahzad has been practising for the last five years with the Neuropsychology Centre in Karachi. While she emphasises that as people’s needs differ their therapy is tailor-made to meet their requirements, there is a general process that she employs when dealing with new clients.

Clients are assessed for IQ, personality traits and emotional level in order to make it easier for the therapist to decide the best ‘approach’. They are also assessed for psychotic disorders that require medical intervention and cannot be solely treated through CBT.

A medical examination of the client is also important in order to ascertain that the root cause is not, for example, a chemical imbalance.

“For instance, depression can also be the result of a thyroid imbalance,” NPC’s Shahzad says, "and therefore CBT would not be an effective approach in such a case."

Again since all therapy sessions are customised the above just offers a general idea of CBT techniques.

To help deal with anxiety (or even panic attacks) breathing techniques are used, the help of audio-visual imagery is made use of along with practising ways of relaxation of both mind and body.

Another important aspect is ‘sleep hygiene’. This focuses on the time a person goes to bed and the quantity they should sleep. To help maintain the regime Shahzad advises, “No eating two hours prior to bedtime, do not write in the diary, avoid having a television in the bedroom, switch off the mobile phone and read a nice, relaxing novel.”

Routine management is another technique by which the client writes down their activities over 24 hours in an hour-by-hour schedule for seven days. The schedule is then discussed with the therapist and the client is responsible for revising the daily agenda and mapping out the following days and weeks as they deem suitable.

“Helping clients formulate goals as part of their therapy and rehabilitation is another critical step,” explains Naheed Khan who is the director for a psychiatric rehabilitation centre, The Recovery House.

Stress management, assertiveness and communication skills are also integral parts of the process.

“This highly structured approach of CBT towards psychological issues is seen by many as a relatively ‘quick fix’ compared to long-drawn psychoanalytic therapies which can take years”, says Bahria University’s Ahmad.

Unravelling our thoughts

As in the case of Khan, experts say it not unusual for men, in even the prime of their adulthood to want time and affection from their wives, and on not receiving it look for the attention elsewhere. While they of course in no way endorse extra-marital relationships, experts do advise deep introspection to understand one’s true feelings first.

“Men tend not to share their feelings with friends or family and bottle them up,” Shahzad explains. “When they sit in a session, we start with a catharsis where they just talk and we listen, no judgement no advice.”

The process of ‘sharing’ helps clients get a huge weight off their shoulders and with tight confidentiality clauses, they are made to feel ‘safe’.

Omar's opportunity to share may have just saved his marriage. He is in counselling now along with his wife trying to reconnect what they shared years ago when they fell in love and married.

*Name has been changed to respect confidentiality